Compared with bare-metal stents, drug-eluting stents (DES) have greatly reduced the risk of in-st... more Compared with bare-metal stents, drug-eluting stents (DES) have greatly reduced the risk of in-stent restenosis (ISR) by inhibiting neointimal growth. Nevertheless, DES are still prone to device failure, which may lead to cardiac events. Recently, stent fracture (SF) has emerged as a potential mechanism of DES failure that is associated with ISR. Stent fracture is strongly related to stent type, and prior reports suggest that deployment of sirolimus eluting stents (SES) may be associated with a higher risk of SF compared to other DES. Everolimus eluting stents (EESs) represent a new generation of DES with promising results. The occurrence of SF with EES has not been well established. The present paper describes two cases of EES fracture associated with ISR.
Background: In this study we compare the outcomes of the paclitaxel-eluting stent (PES) versus th... more Background: In this study we compare the outcomes of the paclitaxel-eluting stent (PES) versus the everolimus-eluting stent (EES) treated patients at a tertiary medical center and up to two years follow up. Methods: Unselected consecutive patients were retrospectively recruited following stenting with PES (159 patients) or EES (189 patients). The first 100 consecutive patients in each cohort underwent syntax scoring. The primary endpoint of the study was target lesion failure (TLF) defined as the combined endpoint of cardiac death, non fatal myocardial infarction or target lesion revascularization (TLR). Secondary endpoints included target vessel revascularization (TVR), target lesion revascularization (TLR), target vessel failure (TVF), acute stent thrombosis (ST), total death, cardiac death, and non fatal myocardial infarction (MI). Analysis was performed with patient number as the denominator. Results: The syntax scores in the 2 groups were similar (20.3 Ϯ 13.9 vs 20.4 Ϯ 13.8, pϭ0.97). Patients treated with the PES stent had less congestive heart failure and restenotic lesions, but a higher prevalence of longer lesions, non left main bifurcations, and required more stents per patient (4.3 Ϯ 2.8 vs. 2.9 Ϯ 2.1). The primary unadjusted outcome of TLF occurred in 29.3% PES vs 20.3% EES (pϭ0.059). The secondary unadjusted endpoints for PES vs EES respectively were: TVF 36.7% vs 28.0% (pϭ0.106), TVR 35.7% vs 26.5% (pϭ0.079), definite and probable ST 1.2% vs 1.6%, non fatal MI 4.5% vs. 4.2%, and cardiac mortality 5.6% vs 3.2%. A propensity matched analysis showed no significant difference in the primary endpoint of TLF (28.6% Ϯ 16 vs 24.6% Ϯ 14, pϭ0.67) in PES vs EES respectively. Conclusion: Using unadjusted analysis, EES had lower TLF than PES in a broad cohort of patients and lesions undergoing PCI. However, when baseline differences between the 2 cohorts were adjusted for, similar efficacy between the PES and EES was seen at 2 years follow-up.
Contrast-induced encephalopathy (CIE) is a rare complication that occurs after exposure to contra... more Contrast-induced encephalopathy (CIE) is a rare complication that occurs after exposure to contrast media, and it usually manifests with transient neurological deficits that include cortical blindness, altered mental status, and paralysis. It is self-limited, and symptoms usually resolve within 48-72 hours. It requires a high index of suspicion and must be taken into consideration in every patient developing a neurological manifestation after the administration of radiocontrast media. We report a case of post-coronary angiography contrast-induced encephalopathy with low-grade fever and negative imaging.
The left ventricle diverticulum is a very rare congenital cardiac malformation that is usually pr... more The left ventricle diverticulum is a very rare congenital cardiac malformation that is usually present during childhood. However, we are reporting the case of an adult patient with a left ventricular diverticulum who presented with chest pain. This paper also highlights the importance of using advanced imaging modalities such as cardiac magnetic resonance, which was essential for diagnosing our case. Our management was conservative, as the patient's chest pain was very mild and resolved within a few days.
Background/purpose: Ovarian clear cell carcinoma (OCCC) with recurrence/progression after treatme... more Background/purpose: Ovarian clear cell carcinoma (OCCC) with recurrence/progression after treatment has dismal prognosis. We aimed to investigate the management and outcomes of such patients. Methods: OCCC patients who were treated between 2000 and 2013 with cancer recurrence or
Journal of the American College of Cardiology, Apr 1, 2014
Relevant clinical history and physical exam: A man aged 61 visited a hospital because he had a su... more Relevant clinical history and physical exam: A man aged 61 visited a hospital because he had a sudden leg pain and lumbago. His left leg pulse was weak and pale. Relevant test results prior to catheterization: CT revealed type B aortic dissection and his lower limb arteries were not enhanced by contrast. In chemistries, the value of CPK was elevated. So he underwent F-F bypass to rescue his limb. The operation was finished safely. But his renal function was worsen remarkably because of malperfusion (Malperfusion is a ischemia of branch artery caused by dissection). Therefore he needed to undergo dialysis. Finally, we decided to do TEVAR to close the entry of dissection. Relevant catheterization findings: The angiography showed that there was very large entry at the distal arch and very small reentry at the right common iliac artery. Besides, there were some reentry parts between them. [Interventional Management] Procedural step: We inserted IVUS after crossing wire. Because of that we could understand the position of the wire and dissection lumen precisely, so we finished closing entry of dissection with TEVAR safely and certainly. Case Summary: It is essential to know the position of entry on TEVAR for aortic dissection. On top of that, we need to know whether the wire was always in the true lumen or not, and whether some abdominal arteries (celiac artery, SMA, renal artery) branch from true lumen or false lumen. If we deployed stentgraft across the wall between true lumen and false lumen, it could be fatal. It is difficult to know where the wire is crossed only via using angiography. Then, it is very useful to use IVUS. Moreover, using IVUS can make contrast to confirm the position less. So it is particularly useful when we treat patients with renal failure caused by malperfusion.
Background: Premedication with benzodiazepines has been thought to reduce patient anxiety, pain p... more Background: Premedication with benzodiazepines has been thought to reduce patient anxiety, pain perception, and non-catheter-induced coronary spasms and may increase procedure-related complications. We used to routinely provide premedication with diazepam and chlorpheniramine before cardiac catheterization procedures. However the benefi ts of such a treatment are not well established here. Therefore, we designed this study to test whether the routine use of premedication during coronary angiography is needed. Methods: A total of 200 consecutive patients scheduled to undergo either diagnostic or therapeutic coronary angiographic procedures were randomized to receive either premedication with diazepam (5 mg) and chlorpheniramine (4 mg) 60 minutes prior to their procedures (n = 100) or no premedication (n = 100). The administration of intravenous midazolam during the procedures was permitted at the operator's discretion. The primary endpoints were anxiety and pain perception during the procedure. Results: A total of 200 patients with similar baseline characteristics were randomized into two groups. The fi rst group received oral premedication with diazepam (5 mg) and chlorphenamine (4 mg) 60 minutes prior to their procedures, and the other group did not receive premedication. We observed no differences in periprocedural pain perception (31% in the premedicated group versus 29% in the non-premedicated group; P = 0.75) or anxiety (59% in the premedicated group versus 50% in the non-premedicated group; P = 0.2). Interestingly, local pain was more pronounced in the premedicated patients than in the non-premedicated patients (30% versus 16%, respectively; P = 0.018). There were no contrast-related reactions reported in either group. Conclusions: Treatment with oral diazepam and chlorphenamine prior to cardiac catheterization and percutaneous coronary intervention does not alter rates of anxiety, periprocedural pain.
Catheterization and Cardiovascular Interventions, Apr 17, 2012
Objectives: Our aim was to compare the outcomes of a same versus different drugeluting stent (DES... more Objectives: Our aim was to compare the outcomes of a same versus different drugeluting stent (DES) implantation strategy for the treatment of DES instent restenosis (ISR). Background: The absence of clear data renders the treatment of DES ISR one of the most challenging situations in interventional cardiology. Methods: We identified all cases of DES ISR treated with a second DES between January 2004 and January 2009. The lesions were divided into those treated with the same DES as the initial one that restenosed and those treated with a different DES. The main end-point was repeat target lesion revascularization (TLR). Results: We included 116 patients with a total of 132 lesions. The patient population was highly complex: 55.5% with diabetes, 56% with type-C lesions, 15.9% with lesions previously stented with BMS and 18.2% with fluoroscopic evidence of stent fracture. A same and different stent strategy was conducted in 41 lesions (31%) and 91 lesions (69%), respectively. Overall TLR was 31.1% and occurred in 46.3% of patients treated with the same stent and 24.4% of those with a different stent (P 5 0.012). Multivariable analysis found same stent strategy (OR 2.84, 95%CI 1.23-6.57;P 5 0.014) and occurrence of stent fracture (OR 4.03, 95%CI 1.33-12.01;P 5 0.012) to be the only independent predictors of TLR after a median follow-up of 20.4 [12.1-30.2] months. Conclusions: In highly complex lesions, DES implantation for DES ISR is linked to a high need of future revascularization. An association between implanting a DES type other than the original and lower rate of TLR is suggested.
Proliferation signal inhibitors may adversely impact bone marrow function. We sought to describe ... more Proliferation signal inhibitors may adversely impact bone marrow function. We sought to describe the impact of sirolimus on hemoglobin and erythropoiesis in heart transplant recipients. We have conducted a single-center, retrospective analysis of all heart transplant patients treated with sirolimus. We measured serum hemoglobin (Hb) at baseline and at 3 months to determine the prevalence of anemia and change in Hb after sirolimus initiation. We also characterized hematologic profile of patients to gain insights into the effects of sirolimus on erythropoiesis. There were 84 patients included in the study. The prevalence of anemia increased from 71% to 75% after sirolimus initiation. Anemic patients were more likely to be male (P = .026) and have worse renal function (glomerular filtration rate 49 ± 27 vs 70 ± 42 mL/min; P = .012). A ≥20 g/L drop in Hb was observed in 25% of the overall cohort. Patients investigated for anemia (n = 67) had a low Hb (111 ± 24 g/L), normal mean corpuscular volume (87 ± 47 FL), and low serum iron levels (10 ± 5 μmol/L) and transferrin saturation (0.22 ± 0.12). Serum ferritin was variable (263 ± 370 μg/L). Bone marrow evaluation in 19 patients revealed adequate marrow iron stores in all cases. Anemia is prevalent in heart transplant patients treated with sirolimus and increases over time. Patients have a characteristic hematologic profile suggestive of anemia of chronic disease and functional iron deficiency.
Immune activation and inflammation play critical roles in the development of heart failure (HF). ... more Immune activation and inflammation play critical roles in the development of heart failure (HF). Human leukocyte antigen-G (HLA-G) is a nonclassical, major histocompatibility complex class I (MHC-I) protein, upregulated in the context of transplantation, malignancy, and inflammation, and has been correlated with various clinical outcomes. We sought to evaluate the utility of plasma HLA-G in identifying patients with HF. We conducted a single-center, cross-sectional pilot study involving 82 patients diagnosed with HF and 10 healthy controls. Concentrations of circulating HLA-G and inflammatory markers were detected with specific enzyme-linked immunosorbent assay kits and quantified according to purified protein standards. The mean age of the patients was 49.1 Ϯ 12.0 years and 62.2% were male. The median and interquartile range of HLA-G levels (U/ml) were significantly higher (p Ͻ 0.001) in HF patients (63, 36-98) compared with controls (28, 22-40). Moreover, HLA-G levels that were similarly (p ϭ 0.766) upregulated across all New York Heart Association functional classes. There was no significant correlation between serum HLA-G and other biomarkers. In conclusion, HLA-G is upregulated in patients diagnosed with HF. Its marked elevation even in New York Heart Association class I patients might indicate that serum HLA-G is a more sensitive marker than other classical HF biomarkers.
Journal of Interventional Cardiology, Sep 20, 2012
Background: Antioxidant drugs such as N-acetylcysteine (NAC) and ascorbic acid have been evaluate... more Background: Antioxidant drugs such as N-acetylcysteine (NAC) and ascorbic acid have been evaluated in interventional studies to prevent contrast-induced nephropathy (CIN), however, there are limited data on comparing either or both, with background of standard intravenous saline hydration versus the standard intravenous saline hydration alone in preventing CIN. Methods: We conducted a single-center randomized trial among patients undergoing coronary angiography or percutaneous coronary intervention who had serum creatinine ≥ 1.3 mg/dL or were on diabetes mellitus medication. Eligible patients were randomly assigned to one of the following 4 groups: (1) NAC, (2) ascorbic acid, (3) combination of both drugs, and (4) control group. Additionally, all the groups received the standard intravenous saline hydration. Creatinine was measured 4-5 days after procedure. Results: A total of 243 patients were randomized; 62 to NAC, 57 to ascorbic acid, 58 to both drugs, and 66 to placebo. The development of 0.5 mg/dL absolute increase of serum creatinine, 25% relative decrease of creatinine clearance, or either (CIN) were measured in the ascorbic acid group (3.6% for all), NAC group (6.8%, 3.4%, 8.5%, respectively), combined group (5.5%, 5.5%, 9.1%, respectively), and control group (6.2%, 6.2%, 7.7%, respectively). None of these differences were significant (P = 0.896 for serum creatinine, P = 0.863 for creatinine clearance, and P = 0.684 for CIN). Conclusions: In a cohort of patients at risk of developing CIN, we could not detect any significant benefit of the use of ascorbic acid, NAC, or a combination of both drugs over the standard hydration regimen in preventing CIN.
Journal of The Saudi Heart Association, Oct 1, 2012
Background: Repair of truncus arteriosus in early infant period has become standard practice in m... more Background: Repair of truncus arteriosus in early infant period has become standard practice in many centers. We report the current clinical outcomes of primary repair of truncus arteriosus in early infancy at a single institution. Methods: A retrospective analysis of 31 patients with mean age 2.6 ± 1.3 months (range, 15 days-6 months), and mean body weight 3.4 ± 0.6 kg (range, 2.6-4.7 kg) who underwent primary repair of truncus arteriosus. Data were collected regarding demographics, anatomy, operative data, cardiac intensive care unit, and last available follow-up. Results: There were four hospital deaths (12.9%); three of them were due to pulmonary hypertension. At median follow up of 8 months (range, 1-100 months) after surgery, there was no late death. One patient was reoperated on for right ventricle-to-pulmonary artery (RV-to-PA) conduit replacement, residual ventricular septal defect repair, and truncal valve repair. One patient was reoperated on twice for truncal valve repair and later on truncal valve replacement. Three patients required percutaneous balloon dilation and stenting of pulmonary artery branches.
Background: Spontaneous coronary artery dissection (SCAD) has remained underdiagnosed for decades... more Background: Spontaneous coronary artery dissection (SCAD) has remained underdiagnosed for decades. Chest pain is the most commonly reported symptom, and coronary angiography remains the gold standard for diagnosis Case: A 71-year old woman with a history of non-ischemic cardiomyopathy for which she had undergone orthotopic heart transplantation 4 years ago, presented for routine coronary angiographic surveillance for detection of cardiac allograft vasculopathy (CAV). Her posttransplant course had been notable for the absence of allograft rejection and CAV. Cardiac catheterization revealed SCAD of the proximal left anterior descending and proximal left circumflex arteries. There was no involvement of the left main and right coronary artery Decision-Making: The patient reported no symptoms referable to cardiac ischemia. She was monitored in an intensive care unit, where she remained hemodynamically stable. An echocardiogram demonstrated normal left ventricular function. As ischemia was felt to be unlikely to manifest as chest pain with a denervated cardiac allograft, serial cardiac markers and electrocardiograms were obtained and were normal. The patient was treated with dual antiplatelet therapy and otherwise managed conservatively for 5 days in the hospital. Her donor was a 38-year-old female Conclusions: We report the rare presentation of SCAD in a cardiac transplant recipient. In this patient population, the presentation of SCAD can be atypical, and the donor's risk factors may play a role
Journal of The Saudi Heart Association, Oct 1, 2012
Background: Repair of truncus arteriosus in early infant period has become standard practice in m... more Background: Repair of truncus arteriosus in early infant period has become standard practice in many centers. We report the current clinical outcomes of primary repair of truncus arteriosus in early infancy at a single institution. Methods: A retrospective analysis of 31 patients with mean age 2.6 ± 1.3 months (range, 15 days-6 months), and mean body weight 3.4 ± 0.6 kg (range, 2.6-4.7 kg) who underwent primary repair of truncus arteriosus. Data were collected regarding demographics, anatomy, operative data, cardiac intensive care unit, and last available follow-up. Results: There were four hospital deaths (12.9%); three of them were due to pulmonary hypertension. At median follow up of 8 months (range, 1-100 months) after surgery, there was no late death. One patient was reoperated on for right ventricle-to-pulmonary artery (RV-to-PA) conduit replacement, residual ventricular septal defect repair, and truncal valve repair. One patient was reoperated on twice for truncal valve repair and later on truncal valve replacement. Three patients required percutaneous balloon dilation and stenting of pulmonary artery branches.
Journal of Heart and Lung Transplantation, Feb 1, 2009
Purpose: Few studies have described the impact of obesity on morbidity and mortality in cardiac t... more Purpose: Few studies have described the impact of obesity on morbidity and mortality in cardiac transplant receipients. Therefore the purpose of this study was to determine wether a change in body mass index (BMI) from before transplant through 5 years after transplant is associated with post transplant morbidity and mortality. Methods and Materials: We retrospectively reviewed 993 consecutive adult patients (821 male, 172 female mean age 51,8) who received a heart transplant from January 1984 to june 2008 at our center. Patients were divided into groups using cutoffs for categories of BMI (Ͻ20, 20-24,25-29, Ն30). Survival and incidence of cardiac allograft vasculopathy (CAVϭirregularity detected by angiography) were compared by Kaplan-Meier analysis. Multiple regression and Cox models were generated to evaluate obesity in multivariate models. pϽ0.05 was defined as significant.
Background: Hypertension is a highly prevalent disease in Saudi Arabia with poor control rates. U... more Background: Hypertension is a highly prevalent disease in Saudi Arabia with poor control rates. Updated guidelines are needed to guide the management of hypertension and improve treatment outcomes. Methodology: A panel of experts representing the National Heart Center (NHC) and the Saudi Heart Association (SHA) reviewed existing evidence and formulated guidance relevant to the local population, clinical practice and the healthcare system. The recommendations were reviewed to ensure scientific and medical accuracy. Recommendations: Hypertension was defined and a new classification was proposed as relevant to the Saudi population. Recommendations on diagnosis, clinical evaluation, cardiovascular assessment were detailed, along with guidance on measurement modalities and screening/follow-up. Non-pharmacological management is the first line of hypertension treatment. Pharmacological therapy should be used appropriately as needed. Treatment priority is to control blood pressure regardless of the drug class used. The choice of treatment should be tailored to the patient profile in order to achieve treatment targets and ensure patient compliance. Recommendations were provided on pharmacological options available in Saudi Arabia, as well as guidance on the treatment of special conditions. Conclusion: Hypertension management should be based on appropriate screening, timely diagnosis and lifestyle changes supplemented with pharmacological therapy, as needed. Clinical management should be individualized, and careful consideration should be given to special conditions and patient groups.
Compared with bare-metal stents, drug-eluting stents (DES) have greatly reduced the risk of in-st... more Compared with bare-metal stents, drug-eluting stents (DES) have greatly reduced the risk of in-stent restenosis (ISR) by inhibiting neointimal growth. Nevertheless, DES are still prone to device failure, which may lead to cardiac events. Recently, stent fracture (SF) has emerged as a potential mechanism of DES failure that is associated with ISR. Stent fracture is strongly related to stent type, and prior reports suggest that deployment of sirolimus eluting stents (SES) may be associated with a higher risk of SF compared to other DES. Everolimus eluting stents (EESs) represent a new generation of DES with promising results. The occurrence of SF with EES has not been well established. The present paper describes two cases of EES fracture associated with ISR.
Background: In this study we compare the outcomes of the paclitaxel-eluting stent (PES) versus th... more Background: In this study we compare the outcomes of the paclitaxel-eluting stent (PES) versus the everolimus-eluting stent (EES) treated patients at a tertiary medical center and up to two years follow up. Methods: Unselected consecutive patients were retrospectively recruited following stenting with PES (159 patients) or EES (189 patients). The first 100 consecutive patients in each cohort underwent syntax scoring. The primary endpoint of the study was target lesion failure (TLF) defined as the combined endpoint of cardiac death, non fatal myocardial infarction or target lesion revascularization (TLR). Secondary endpoints included target vessel revascularization (TVR), target lesion revascularization (TLR), target vessel failure (TVF), acute stent thrombosis (ST), total death, cardiac death, and non fatal myocardial infarction (MI). Analysis was performed with patient number as the denominator. Results: The syntax scores in the 2 groups were similar (20.3 Ϯ 13.9 vs 20.4 Ϯ 13.8, pϭ0.97). Patients treated with the PES stent had less congestive heart failure and restenotic lesions, but a higher prevalence of longer lesions, non left main bifurcations, and required more stents per patient (4.3 Ϯ 2.8 vs. 2.9 Ϯ 2.1). The primary unadjusted outcome of TLF occurred in 29.3% PES vs 20.3% EES (pϭ0.059). The secondary unadjusted endpoints for PES vs EES respectively were: TVF 36.7% vs 28.0% (pϭ0.106), TVR 35.7% vs 26.5% (pϭ0.079), definite and probable ST 1.2% vs 1.6%, non fatal MI 4.5% vs. 4.2%, and cardiac mortality 5.6% vs 3.2%. A propensity matched analysis showed no significant difference in the primary endpoint of TLF (28.6% Ϯ 16 vs 24.6% Ϯ 14, pϭ0.67) in PES vs EES respectively. Conclusion: Using unadjusted analysis, EES had lower TLF than PES in a broad cohort of patients and lesions undergoing PCI. However, when baseline differences between the 2 cohorts were adjusted for, similar efficacy between the PES and EES was seen at 2 years follow-up.
Contrast-induced encephalopathy (CIE) is a rare complication that occurs after exposure to contra... more Contrast-induced encephalopathy (CIE) is a rare complication that occurs after exposure to contrast media, and it usually manifests with transient neurological deficits that include cortical blindness, altered mental status, and paralysis. It is self-limited, and symptoms usually resolve within 48-72 hours. It requires a high index of suspicion and must be taken into consideration in every patient developing a neurological manifestation after the administration of radiocontrast media. We report a case of post-coronary angiography contrast-induced encephalopathy with low-grade fever and negative imaging.
The left ventricle diverticulum is a very rare congenital cardiac malformation that is usually pr... more The left ventricle diverticulum is a very rare congenital cardiac malformation that is usually present during childhood. However, we are reporting the case of an adult patient with a left ventricular diverticulum who presented with chest pain. This paper also highlights the importance of using advanced imaging modalities such as cardiac magnetic resonance, which was essential for diagnosing our case. Our management was conservative, as the patient's chest pain was very mild and resolved within a few days.
Background/purpose: Ovarian clear cell carcinoma (OCCC) with recurrence/progression after treatme... more Background/purpose: Ovarian clear cell carcinoma (OCCC) with recurrence/progression after treatment has dismal prognosis. We aimed to investigate the management and outcomes of such patients. Methods: OCCC patients who were treated between 2000 and 2013 with cancer recurrence or
Journal of the American College of Cardiology, Apr 1, 2014
Relevant clinical history and physical exam: A man aged 61 visited a hospital because he had a su... more Relevant clinical history and physical exam: A man aged 61 visited a hospital because he had a sudden leg pain and lumbago. His left leg pulse was weak and pale. Relevant test results prior to catheterization: CT revealed type B aortic dissection and his lower limb arteries were not enhanced by contrast. In chemistries, the value of CPK was elevated. So he underwent F-F bypass to rescue his limb. The operation was finished safely. But his renal function was worsen remarkably because of malperfusion (Malperfusion is a ischemia of branch artery caused by dissection). Therefore he needed to undergo dialysis. Finally, we decided to do TEVAR to close the entry of dissection. Relevant catheterization findings: The angiography showed that there was very large entry at the distal arch and very small reentry at the right common iliac artery. Besides, there were some reentry parts between them. [Interventional Management] Procedural step: We inserted IVUS after crossing wire. Because of that we could understand the position of the wire and dissection lumen precisely, so we finished closing entry of dissection with TEVAR safely and certainly. Case Summary: It is essential to know the position of entry on TEVAR for aortic dissection. On top of that, we need to know whether the wire was always in the true lumen or not, and whether some abdominal arteries (celiac artery, SMA, renal artery) branch from true lumen or false lumen. If we deployed stentgraft across the wall between true lumen and false lumen, it could be fatal. It is difficult to know where the wire is crossed only via using angiography. Then, it is very useful to use IVUS. Moreover, using IVUS can make contrast to confirm the position less. So it is particularly useful when we treat patients with renal failure caused by malperfusion.
Background: Premedication with benzodiazepines has been thought to reduce patient anxiety, pain p... more Background: Premedication with benzodiazepines has been thought to reduce patient anxiety, pain perception, and non-catheter-induced coronary spasms and may increase procedure-related complications. We used to routinely provide premedication with diazepam and chlorpheniramine before cardiac catheterization procedures. However the benefi ts of such a treatment are not well established here. Therefore, we designed this study to test whether the routine use of premedication during coronary angiography is needed. Methods: A total of 200 consecutive patients scheduled to undergo either diagnostic or therapeutic coronary angiographic procedures were randomized to receive either premedication with diazepam (5 mg) and chlorpheniramine (4 mg) 60 minutes prior to their procedures (n = 100) or no premedication (n = 100). The administration of intravenous midazolam during the procedures was permitted at the operator's discretion. The primary endpoints were anxiety and pain perception during the procedure. Results: A total of 200 patients with similar baseline characteristics were randomized into two groups. The fi rst group received oral premedication with diazepam (5 mg) and chlorphenamine (4 mg) 60 minutes prior to their procedures, and the other group did not receive premedication. We observed no differences in periprocedural pain perception (31% in the premedicated group versus 29% in the non-premedicated group; P = 0.75) or anxiety (59% in the premedicated group versus 50% in the non-premedicated group; P = 0.2). Interestingly, local pain was more pronounced in the premedicated patients than in the non-premedicated patients (30% versus 16%, respectively; P = 0.018). There were no contrast-related reactions reported in either group. Conclusions: Treatment with oral diazepam and chlorphenamine prior to cardiac catheterization and percutaneous coronary intervention does not alter rates of anxiety, periprocedural pain.
Catheterization and Cardiovascular Interventions, Apr 17, 2012
Objectives: Our aim was to compare the outcomes of a same versus different drugeluting stent (DES... more Objectives: Our aim was to compare the outcomes of a same versus different drugeluting stent (DES) implantation strategy for the treatment of DES instent restenosis (ISR). Background: The absence of clear data renders the treatment of DES ISR one of the most challenging situations in interventional cardiology. Methods: We identified all cases of DES ISR treated with a second DES between January 2004 and January 2009. The lesions were divided into those treated with the same DES as the initial one that restenosed and those treated with a different DES. The main end-point was repeat target lesion revascularization (TLR). Results: We included 116 patients with a total of 132 lesions. The patient population was highly complex: 55.5% with diabetes, 56% with type-C lesions, 15.9% with lesions previously stented with BMS and 18.2% with fluoroscopic evidence of stent fracture. A same and different stent strategy was conducted in 41 lesions (31%) and 91 lesions (69%), respectively. Overall TLR was 31.1% and occurred in 46.3% of patients treated with the same stent and 24.4% of those with a different stent (P 5 0.012). Multivariable analysis found same stent strategy (OR 2.84, 95%CI 1.23-6.57;P 5 0.014) and occurrence of stent fracture (OR 4.03, 95%CI 1.33-12.01;P 5 0.012) to be the only independent predictors of TLR after a median follow-up of 20.4 [12.1-30.2] months. Conclusions: In highly complex lesions, DES implantation for DES ISR is linked to a high need of future revascularization. An association between implanting a DES type other than the original and lower rate of TLR is suggested.
Proliferation signal inhibitors may adversely impact bone marrow function. We sought to describe ... more Proliferation signal inhibitors may adversely impact bone marrow function. We sought to describe the impact of sirolimus on hemoglobin and erythropoiesis in heart transplant recipients. We have conducted a single-center, retrospective analysis of all heart transplant patients treated with sirolimus. We measured serum hemoglobin (Hb) at baseline and at 3 months to determine the prevalence of anemia and change in Hb after sirolimus initiation. We also characterized hematologic profile of patients to gain insights into the effects of sirolimus on erythropoiesis. There were 84 patients included in the study. The prevalence of anemia increased from 71% to 75% after sirolimus initiation. Anemic patients were more likely to be male (P = .026) and have worse renal function (glomerular filtration rate 49 ± 27 vs 70 ± 42 mL/min; P = .012). A ≥20 g/L drop in Hb was observed in 25% of the overall cohort. Patients investigated for anemia (n = 67) had a low Hb (111 ± 24 g/L), normal mean corpuscular volume (87 ± 47 FL), and low serum iron levels (10 ± 5 μmol/L) and transferrin saturation (0.22 ± 0.12). Serum ferritin was variable (263 ± 370 μg/L). Bone marrow evaluation in 19 patients revealed adequate marrow iron stores in all cases. Anemia is prevalent in heart transplant patients treated with sirolimus and increases over time. Patients have a characteristic hematologic profile suggestive of anemia of chronic disease and functional iron deficiency.
Immune activation and inflammation play critical roles in the development of heart failure (HF). ... more Immune activation and inflammation play critical roles in the development of heart failure (HF). Human leukocyte antigen-G (HLA-G) is a nonclassical, major histocompatibility complex class I (MHC-I) protein, upregulated in the context of transplantation, malignancy, and inflammation, and has been correlated with various clinical outcomes. We sought to evaluate the utility of plasma HLA-G in identifying patients with HF. We conducted a single-center, cross-sectional pilot study involving 82 patients diagnosed with HF and 10 healthy controls. Concentrations of circulating HLA-G and inflammatory markers were detected with specific enzyme-linked immunosorbent assay kits and quantified according to purified protein standards. The mean age of the patients was 49.1 Ϯ 12.0 years and 62.2% were male. The median and interquartile range of HLA-G levels (U/ml) were significantly higher (p Ͻ 0.001) in HF patients (63, 36-98) compared with controls (28, 22-40). Moreover, HLA-G levels that were similarly (p ϭ 0.766) upregulated across all New York Heart Association functional classes. There was no significant correlation between serum HLA-G and other biomarkers. In conclusion, HLA-G is upregulated in patients diagnosed with HF. Its marked elevation even in New York Heart Association class I patients might indicate that serum HLA-G is a more sensitive marker than other classical HF biomarkers.
Journal of Interventional Cardiology, Sep 20, 2012
Background: Antioxidant drugs such as N-acetylcysteine (NAC) and ascorbic acid have been evaluate... more Background: Antioxidant drugs such as N-acetylcysteine (NAC) and ascorbic acid have been evaluated in interventional studies to prevent contrast-induced nephropathy (CIN), however, there are limited data on comparing either or both, with background of standard intravenous saline hydration versus the standard intravenous saline hydration alone in preventing CIN. Methods: We conducted a single-center randomized trial among patients undergoing coronary angiography or percutaneous coronary intervention who had serum creatinine ≥ 1.3 mg/dL or were on diabetes mellitus medication. Eligible patients were randomly assigned to one of the following 4 groups: (1) NAC, (2) ascorbic acid, (3) combination of both drugs, and (4) control group. Additionally, all the groups received the standard intravenous saline hydration. Creatinine was measured 4-5 days after procedure. Results: A total of 243 patients were randomized; 62 to NAC, 57 to ascorbic acid, 58 to both drugs, and 66 to placebo. The development of 0.5 mg/dL absolute increase of serum creatinine, 25% relative decrease of creatinine clearance, or either (CIN) were measured in the ascorbic acid group (3.6% for all), NAC group (6.8%, 3.4%, 8.5%, respectively), combined group (5.5%, 5.5%, 9.1%, respectively), and control group (6.2%, 6.2%, 7.7%, respectively). None of these differences were significant (P = 0.896 for serum creatinine, P = 0.863 for creatinine clearance, and P = 0.684 for CIN). Conclusions: In a cohort of patients at risk of developing CIN, we could not detect any significant benefit of the use of ascorbic acid, NAC, or a combination of both drugs over the standard hydration regimen in preventing CIN.
Journal of The Saudi Heart Association, Oct 1, 2012
Background: Repair of truncus arteriosus in early infant period has become standard practice in m... more Background: Repair of truncus arteriosus in early infant period has become standard practice in many centers. We report the current clinical outcomes of primary repair of truncus arteriosus in early infancy at a single institution. Methods: A retrospective analysis of 31 patients with mean age 2.6 ± 1.3 months (range, 15 days-6 months), and mean body weight 3.4 ± 0.6 kg (range, 2.6-4.7 kg) who underwent primary repair of truncus arteriosus. Data were collected regarding demographics, anatomy, operative data, cardiac intensive care unit, and last available follow-up. Results: There were four hospital deaths (12.9%); three of them were due to pulmonary hypertension. At median follow up of 8 months (range, 1-100 months) after surgery, there was no late death. One patient was reoperated on for right ventricle-to-pulmonary artery (RV-to-PA) conduit replacement, residual ventricular septal defect repair, and truncal valve repair. One patient was reoperated on twice for truncal valve repair and later on truncal valve replacement. Three patients required percutaneous balloon dilation and stenting of pulmonary artery branches.
Background: Spontaneous coronary artery dissection (SCAD) has remained underdiagnosed for decades... more Background: Spontaneous coronary artery dissection (SCAD) has remained underdiagnosed for decades. Chest pain is the most commonly reported symptom, and coronary angiography remains the gold standard for diagnosis Case: A 71-year old woman with a history of non-ischemic cardiomyopathy for which she had undergone orthotopic heart transplantation 4 years ago, presented for routine coronary angiographic surveillance for detection of cardiac allograft vasculopathy (CAV). Her posttransplant course had been notable for the absence of allograft rejection and CAV. Cardiac catheterization revealed SCAD of the proximal left anterior descending and proximal left circumflex arteries. There was no involvement of the left main and right coronary artery Decision-Making: The patient reported no symptoms referable to cardiac ischemia. She was monitored in an intensive care unit, where she remained hemodynamically stable. An echocardiogram demonstrated normal left ventricular function. As ischemia was felt to be unlikely to manifest as chest pain with a denervated cardiac allograft, serial cardiac markers and electrocardiograms were obtained and were normal. The patient was treated with dual antiplatelet therapy and otherwise managed conservatively for 5 days in the hospital. Her donor was a 38-year-old female Conclusions: We report the rare presentation of SCAD in a cardiac transplant recipient. In this patient population, the presentation of SCAD can be atypical, and the donor's risk factors may play a role
Journal of The Saudi Heart Association, Oct 1, 2012
Background: Repair of truncus arteriosus in early infant period has become standard practice in m... more Background: Repair of truncus arteriosus in early infant period has become standard practice in many centers. We report the current clinical outcomes of primary repair of truncus arteriosus in early infancy at a single institution. Methods: A retrospective analysis of 31 patients with mean age 2.6 ± 1.3 months (range, 15 days-6 months), and mean body weight 3.4 ± 0.6 kg (range, 2.6-4.7 kg) who underwent primary repair of truncus arteriosus. Data were collected regarding demographics, anatomy, operative data, cardiac intensive care unit, and last available follow-up. Results: There were four hospital deaths (12.9%); three of them were due to pulmonary hypertension. At median follow up of 8 months (range, 1-100 months) after surgery, there was no late death. One patient was reoperated on for right ventricle-to-pulmonary artery (RV-to-PA) conduit replacement, residual ventricular septal defect repair, and truncal valve repair. One patient was reoperated on twice for truncal valve repair and later on truncal valve replacement. Three patients required percutaneous balloon dilation and stenting of pulmonary artery branches.
Journal of Heart and Lung Transplantation, Feb 1, 2009
Purpose: Few studies have described the impact of obesity on morbidity and mortality in cardiac t... more Purpose: Few studies have described the impact of obesity on morbidity and mortality in cardiac transplant receipients. Therefore the purpose of this study was to determine wether a change in body mass index (BMI) from before transplant through 5 years after transplant is associated with post transplant morbidity and mortality. Methods and Materials: We retrospectively reviewed 993 consecutive adult patients (821 male, 172 female mean age 51,8) who received a heart transplant from January 1984 to june 2008 at our center. Patients were divided into groups using cutoffs for categories of BMI (Ͻ20, 20-24,25-29, Ն30). Survival and incidence of cardiac allograft vasculopathy (CAVϭirregularity detected by angiography) were compared by Kaplan-Meier analysis. Multiple regression and Cox models were generated to evaluate obesity in multivariate models. pϽ0.05 was defined as significant.
Background: Hypertension is a highly prevalent disease in Saudi Arabia with poor control rates. U... more Background: Hypertension is a highly prevalent disease in Saudi Arabia with poor control rates. Updated guidelines are needed to guide the management of hypertension and improve treatment outcomes. Methodology: A panel of experts representing the National Heart Center (NHC) and the Saudi Heart Association (SHA) reviewed existing evidence and formulated guidance relevant to the local population, clinical practice and the healthcare system. The recommendations were reviewed to ensure scientific and medical accuracy. Recommendations: Hypertension was defined and a new classification was proposed as relevant to the Saudi population. Recommendations on diagnosis, clinical evaluation, cardiovascular assessment were detailed, along with guidance on measurement modalities and screening/follow-up. Non-pharmacological management is the first line of hypertension treatment. Pharmacological therapy should be used appropriately as needed. Treatment priority is to control blood pressure regardless of the drug class used. The choice of treatment should be tailored to the patient profile in order to achieve treatment targets and ensure patient compliance. Recommendations were provided on pharmacological options available in Saudi Arabia, as well as guidance on the treatment of special conditions. Conclusion: Hypertension management should be based on appropriate screening, timely diagnosis and lifestyle changes supplemented with pharmacological therapy, as needed. Clinical management should be individualized, and careful consideration should be given to special conditions and patient groups.
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